Hypercalcemia in renal transplant patients: prevalence and management in Canadian transplant practice.

Hypercalcemia, occurring in up to 25% of patients within 12 months following renal transplantation, and persistent hyperparathyroidism were evaluated following renal transplantation, by retrospective chart review of 1000 adult patients transplanted between January 1, 2003 and January 31, 2008 with at least six months follow-up. Serum calcium, parathyroid hormone, and phosphate levels were recorded at 12, 24, 36, and 48 months. Average follow-up was 766 (535) d (mean (SD); median 668 d). Majority were first transplants (85%); deceased donor 57%. Point prevalence of hypercalcemia (serum Ca(2+) > 2.6 mM) was 16.6% at month 12, 13.6% at month 24, 9.5% at month 36, and 10.1% at month 48. Point prevalence of serum parathyroid hormone (PTH) > 10 pM was 47.6% at month 12, 51.1% at month 24, 43.4% at month 36, and 39.3% at month 48. Estimated glomerular filtration rate (GFR) was maintained throughout and was not different between patients with or without hypercalcemia or elevated PTH. Cinacalcet was prescribed in 12% of patients with hypercalcemia and persistent hyperparathyroidism; parathyroidectomy was performed in 112/1000 patients, 15 post-transplant. Persistent hyperparathyroidism, often accompanied by hypercalcemia, is common following successful renal transplantation, but the lack of clear management suggests the need for further study and development of evidence-based guidelines.

The economic viability of breast reconstruction in the UK: comparison of a single surgeon's experience of implant; LD; TRAM and DIEP based reconstructions in 274 patients.

A retrospective audit was performed of patients undergoing breast reconstruction under the care of the senior author from 2000 to 2007. We documented reconstruction type, length of stay and total number of revisions. Income to the trust based on the 2008/9 HRG codes along with any "top ups" was also recorded. This was compared to calculations of cost to the trust of performing each reconstruction. 274 patients had 278 primary reconstructions and a further 366 revisions. Only patients with a minimum one-year's follow-up were included (mean 3 years). This included 68 DIEPs'; 39 TRAMs'; 98 LDs'; and 73 implant reconstructions. The median length of stay for implant based reconstruction was 4 days; 9 for LD flaps; 11 for TRAMs' and 8 for DIEPs'. This was significantly shorter for the implant group compared to other reconstructions (P<0.001). The mean number of surgical revisions was 1.5 for implant reconstructions; 1.6 for LDs; 0.9 for TRAMs' and 0.8 for DIEPs'. There were significantly more revisions of implant reconstructions than DIEPs (P=0.037) and significantly more revisions of LDs compared to TRAM and DIEPs' (P=0.012 and 0.0023). In our study, the cost of an LD, TRAM or DIEP reconstruction including both primary surgery and any revisions was similar, and while at an average of three years, the implant reconstruction remains cheaper, that patient will still require more revisions, and if followed up enough will lose this small financial benefit. Furthermore, the difference is small (£8034 for implants vs. £10910 for DIEPs), and it could be argued this is justified by the increased patient satisfaction and cosmetic outcome. Finally we highlight several areas of financial inequality, including insufficient remuneration for providing individual operations, the lack of payment for performing more than one procedure at the same time and lack of payment for bilateral procedures.

Chronic kidney disease: why is current management uncoordinated and suboptimal?

Morbidity and mortality associated with chronic kidney disease (CKD) is higher than that of the normal population, and the incidence of end-stage renal disease (ESRD) continues to increase. Several factors contribute to the uncoordinated and suboptimal management of CKD, including the attitude and behaviour of nephrologists, referring physicians and patients, and economic constraints on healthcare systems. Late referral of at-risk patients to specialist care is an area of particular concern, as this denies nephrologists adequate opportunity to prevent progression of CKD and associated complications such as anaemia. Due to the ageing population and advances in technology, the costs of treating CKD and ESRD continue to escalate and represent another barrier to the delivery of optimal care. Optimizing the care provided to CKD patients requires a coordinated approach to the management of the condition. Closer collaboration and improved communication across specialities is important for the timely referral of patients and for efficient utilization of available resources. A multidisciplinary approach may facilitate patient identification and improve the management of CKD.

A study of the quality of life and cost-utility of renal transplantation.

The objective of this study was to assess the cost-utility of renal transplantation compared with dialysis. To accomplish this, a prospective cohort of pre-transplant patients were followed for up to two years after renal transplantation at three University-based Canadian hospitals. A total of 168 patients were followed for an average of 19.5 months after transplantation. Health-related quality of life was assessed using a hemodialysis questionnaire, a transplant questionnaire, the Sickness Impact Profile, and the Time Trade-Off Technique. Fully allocated costs were determined by prospectively recording resource use in all patients. A societal perspective was taken. By six months after transplantation, the mean health-related quality of life scores of almost all measures had improved compared to pre-transplantation, and they stayed improved throughout the two years of follow up. The mean time trade-off score was 0.57 pre-transplant and 0.70 two years after transplantation. The proportion of individuals employed increased from 30% before transplantation to 45% two years after transplantation. Employment prior to transplantation [relative risk (RR) = 23], graft function (RR 10) and age (RR 1.6 for every decrease in age by one decade), independently predicted employment status after transplantation. The cost of pre-transplant care ($66,782 Can 1994) and the cost of the first year after transplantation ($66,290) were similar. Transplantation was considerably less expensive during the second year after transplantation ($27,875). Over the two years, transplantation was both more effective and less costly than dialysis. This was true for all subgroups of patients examined, including patients older than 60 and diabetics. We conclude that renal transplantation was more effective and less costly than dialysis in all subgroups of patients examined.

Effect of anaemia correction on skeletal muscle metabolism in patients with end-stage renal disease: 31P magnetic resonance spectroscopy assessment.

Skeletal muscle metabolism during exercise was compared in 5 patients with end-stage renal disease (ESRD) and 8 healthy controls, using a noninvasive technique, 31P magnetic resonance spectroscopy (MRS). After 3 months of anaemia correction with recombinant human erythropoietin (rHuEPO) these patients were re-evaluated. Maximal power achieved by the ESRD patients during a dynamic wrist flexion exercise test was 33% lower (p < 0.05) than the controls. Similarly in the ESRD group, the power at the onset of metabolic acidosis (the intracellular threshold) was 29% less than controls. The metabolic differences observed in the patients indicated a lower aerobic capacity. Three months of rHuEPO treatment resulted in a 55% increase in mean haematocrit but conferred no significant improvement in metabolic parameters at rest or during exercise. The lack of any significant changes in muscle metabolism following the correction of anaemia suggests that oxygen availability is not the exclusive limiting factor for aerobic metabolism in ESRD patients.

The impact of recombinant human erythropoietin on medical care costs for hemodialysis patients in Canada.

Recombinant human erythropoietin (r-HuEPO) is an established and effective therapy for anemia related to end stage renal disease. In addition to its clinical effects, it has been associated with significant improvements in quality of life for anemic hemodialysis patients. The therapy's impact on overall medical care expenditures for these patients remains uncertain, however. In this study, we examine the costs of r-HuEPO as well as potential offsetting reductions in other medical care costs that might result from the therapy. We used data from a randomized clinical trial, a longitudinal study of hemodialysis patients and the clinical literature to estimate the impact of r-HuEPO on transfusion requirements, transfusion-related illness, hospitalization and transplant success for these patients. We estimate that for patients that otherwise would be transfused, the therapy would reduce blood requirements by nearly 10 units per patient annually and hospital use by 8 days per year. In addition, increased transplant success due to r-HuEPO might result in 150 fewer patient months of dialysis treatments each year. Comparing the dollar value of these reductions with the cost of therapy yields a base case net increase in medical care expenditures of $3425 per patient year. Under varying assumptions, the estimates range from a net cost of $8320 to a net saving of $1775 per patient year.